From the case files…

Each issue the team that bring you Casebook share two interesting general practice cases

Tunnel vision

Forty-nine-year-old Mrs S visited her GP, Dr Y, with a recent onset of pain in the middle of her back extending down her right shoulder. She had also been suffering from a recent flu-like illness. She had a 15-year history of chronic neck and left arm pain due to cervical spondylosis.

Dr Y documented that she had a worsening pain and a pain over her left breast, where she had had pleurisy in the past. Her chest was clear on examination and he advised physiotherapy. Mrs S’s pain worsened and she attended the local Emergency Department (ED) where she was diagnosed with a chest infection and discharged with antibiotics.

Five days later Mrs S had developed numbness in her right arm, the pain had become more severe and she was experiencing fever and night sweats. Dr O visited her at home, found her to be pale and clammy with a pulse of 100, but normal blood pressure. He documented no tenderness between the scapulae or over her cervical spine, power in her right arm was noted to be 4/5, bronchial breathing was present at the left base. He changed her antibiotics and arranged to review her in the morning.

The next day, Sunday, Mrs S was starting to feel better and her observations were normal. Dr O reviewed Mrs S on Monday; she told him that the pain was still severe between her scapulae, but that her right arm was improving. She requested an HIV test. Dr O noted that her chest was clear and arranged a full blood count and plasma viscosity in addition to the HIV test.

He asked her to attend the hospital for a chest x-ray and cervical spine x-ray. Dr O reviewed the patient the following Monday. Mrs S continued to complain of severe pain between her scapulae and of right-arm numbness. She also told Dr O that her right hand was clawing although this is not documented in the records. Dr O wrote that the chest x-ray showed chronic inflammation within the lungs and the spinal x-ray demonstrated chronic osteoarthritis in the cervical and thoracic spine. Dr O did not examine Mrs S but arranged more blood tests.

Mrs S continued to complain of severe pain between her scapulae and of right-arm numbness. She also told Dr O that her right hand was clawing although this is not documented in the records

Two days later Mrs S awoke with severe leg pain and called an ambulance. She was seen by Dr C in the ED who discharged her advising an MRI scan would be arranged by her GP.

Later that day, Mrs S awoke to find that she was experiencing paralysis from the waist down and had been incontinent of urine. She was taken by ambulance back to ED where an MRI scan revealed the presence of a spinal abscess at C6/7. Mrs S was transferred to the regional neurosurgery centre where she underwent an emergency laminectomy the following day. Unfortunately, neurological damage had already occurred and for two months she was paralysed from the chest down.

Her legs improved but Mrs S continued to have problems with her mobility, only being able to walk short distances. She had to be re-homed since her current house had steep stairs. Her right arm remained painful and weak with little function and she experienced episodes of urinary incontinence and had to self-catheterise. Mrs S made a claim against Dr O and Dr C.

Expert opinion

Although a spinal abscess may be difficult to diagnose, Dr O could be criticised in relation to his standard of care. Dr O’s record-keeping was felt to be inadequate, and he should have carried out a comprehensive neurological examination on that second Monday, including testing the power and sensation in all limbs and palpating the spine for tenderness. Had Dr O done so he would have detected abnormalities and the patient should have been urgently admitted to hospital that day.

Expert neurosurgical opinion was that early diagnosis would have led to a better outcome, and the patient may have preserved most or all of her function. The hospital care in the ED was also criticised. The claim was settled for a large sum, apportioned between the hospital and Dr O.

Learning points

Spinal abscesses are not common and may be difficult to diagnose especially if a patient has coexisting neck pathology.

Mrs S had been experiencing an intermittent pyrexia, which persisted despite treating her presumed chest infection with two courses of antibiotics. An intermittent pyrexia is suggestive of an abscess.

In any patient with a persistent fever you should look for the cause of the fever and consider all presenting symptoms carefully.

If a patient has existing neck pathology it is a common trap to assume that the new symptoms are a gradual progression of this. Try to avoid linking all the symptoms together and instead consider carefully whether something new might be occurring.

Ensure that in any patient with neurological symptoms you take a good history and perform a full and comprehensive neurological examination. In this case the examination findings may have led Dr O to detect the evolving spinal abscess at an earlier stage, which would have led to a better outcome for the patient.

Do not hesitate to reconsider your diagnosis if the clinical picture no longer fits this and always consider obtaining a second opinion from a colleague or telephoning hospital specialists for advice.

The heart of the problem

Mr P, a 56-year-old keen athlete, attended his GP, Dr M, with episodes of tight central chest pain while running. He was a non-smoker and had no family history of heart disease. He had a history of rectal carcinoma for which he had had a bowel resection four years previously.

Dr M arranged for bloods and an ECG and, in view of his previous cancer, a chest x-ray. The results of the bloods and chest x-ray were normal. The result of the ECG is not documented. Dr M arranged for Mr P to have an exercise ECG. The exercise ECG was reported as normal by Dr H at the hospital. It was stated that Mr P did not develop any chest pain during the exercise ECG test.

Mr P reported that his symptoms had almost settled. Dr M advised a trial of a proton pump inhibitor and documented that he felt Mr P had an element of anxiety about his cancer diagnosis and his stoma. However, Dr M stated that the patient would require cardiology referral if things did not settle.

Fourteen months later, Mr P presented to Dr M with right-sided chest pain on exertion and also at rest. Nothing else was documented about the nature of the pain, although it was so severe that Mr P had decided to stop exercising due to the pain. There was no dyspepsia, appetite was good and Mr P’s weight was stable. Dr M noted that Mr P’s chest was clear but did not document a cardiovascular examination. Dr M noted that the chest x-ray and ECG were satisfactory the previous year and advised a proton pump inhibitor.

Nine months later, Mr P attended Dr M to discuss the results of a recent colonoscopy for rectal bleeding. Dr M did not enquire about the chest pain. He documented that the patient was going to visit his family in Canada. Two months later, Mr P passed away in Canada. At postmortem the cause of death was found to be myocardial infarction. Mr P’s widow made a claim against Dr M.

Expert opinion

Fourteen months later, Mr P presented to Dr M with right-sided chest pain on exertion and also at rest. Nothing else was documented about the nature of the pain

Expert opinion was critical of Dr M for not referring Mr P to cardiology at the first presentation, even in the presence of a negative exercise ECG, as the history was suggestive of classical angina pain (and particularly in light of the fact that the exercise ECG did not provoke any chest pain). It was also felt that Mr P should have been actively followed up to assess his response to the proton pump inhibitor and a cardiology referral made if the pain did not settle.

At the second presentation Dr M’s record-keeping was criticised as there was poor documentation of the nature of the pain and no assessment of how effective the proton pump inhibitor had been in the past. Dr M ignored his previous plan in the records to refer to cardiology if the pain did not settle.

An expert cardiology opinion concluded that, on the balance of probabilities, if Mr P had been referred to a cardiologist at either the first or the second presentation, he would have been diagnosed with coronary artery disease and would have had treatment, either medical or surgical, to reduce the incidence of angina and the risk of myocardial infarction. The claim was settled for a moderate sum.

Learning points

In any patient with chest pain, you should exclude a cardiac cause with a careful history, examination, investigation and ongoing referral to cardiology if there is any concern about the diagnosis.

It is well-documented that exercise ECG tests may be unreliable. In this case Mr P did not experience chest pain during the test and it was therefore not possible to exclude angina on the basis of this test alone.

Each time a patient presents with chest pain, you should make a note of the nature of the pain, its position, radiation and any relieving, precipitating or associated factors.

Do not assume that the pain is the same pain as at the patient’s last presentation – pain should be reassessed at each presentation, especially if it is failing to settle.

Be very cautious in attributing symptoms to anxiety and exclude all serious physical causes first.

Follow up the patient after a trial of treatment, where the diagnosis is unclear, and consider referral to secondary care for advice or a second opinion if symptoms fail to settle.

Consider putting reminders, such as “If symptoms do not settle refer cardiology” in bold in the records so they do not subsequently get missed.

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